Referral form for wellbeing workshops

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Workshop location *

Which programme are you interested in? *

Writing for Wellbeing

Art for Wellbeing

Drama for Wellbeing

Drumming for Wellbeing

Woodwork for Wellbeing

Dance for Wellbeing

Other:

First name of individual *

Last name of individual *

Telephone number *

Email address *

Postcode *

Gender *

Male

Female

Other

Other:

Home country *

Ethnicity *

Indian or British Indian

Pakistani or British Pakistani

Bangladeshi or British Bangladeshi

Chinese or British Chinese

Any other Asian background

Black Caribbean

Black African

Any other Black, Black British, or Caribbean background

Mixed White and Black Caribbean

Mixed White and Black African

Mixed White and Asian

Any other Mixed or multiple ethnic background

White English, Welsh, Scottish, Northern Irish or British

White Irish

Gypsy or Irish Traveller

Roma

Any other White background

Arab

Any other ethnic group

Language(s) spoken *

Date of birth *

YYYY

Immigration status (if known) *

British citizen

Leave to remain

Asylum seeker

Refugee

Student visa

Other

Other:

Who referred you to us? / How did you find out about us? *

Please provide details of any food intolerants? (for refreshments purposes)

Phone number and name of a contact for emergencies *

Is there anything we should know about your ability to be able to access our wellbeing services? (eg. communication needs, medical needs, sensory needs and triggers)

Form completed by *

Occasionally we like to take photos in our workshops.

Please choose one of the following options:

I give permission for my photo to be taken and for it to be used on social media / media

I give permission for my photo to be taken but NOT used on social media / media

I do not want my photo taken at all

Data protection - we are committed to treating your personal data effectively under UK GDPR. The above data helps us to ensure we can support you effectively on your wellbeing journey. We may also use your data for statistical analysis/monitoring purposes. Your data will not be shared with third parties without informing you. Please indicate below your consent to our retaining your data for these purposes. For more details about our Data Protection Policy, or to withdraw consent, please contact the Data Protection Officer at kaleidoarts@protonmail.com.
*

I consent to Kaleido Arts for Wellbeing retaining my personal data as outlined above.

Required

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